Theor Med Bioeth
DOI 10.1007/s11017-011-9180-2
Agency and authenticity: Which value grounds
patient choice?
Daniel Brudney • John Lantos
Springer Science+Business Media B.V. 2011
Abstract In current American medical practice, autonomy is assumed to be more
valuable than human life: if a patient autonomously refuses lifesaving treatment, the
doctors are supposed to let him die. In this paper we discuss two values that might
be at stake in such clinical contexts. Usually, we hear only of autonomy and best
interests. However, here, autonomy is ambiguous between two concepts—concepts
that are tied to different values and to different philosophical traditions. In some
cases, the two values (that of agency and that of authenticity) entail different outcomes. We argue that the comparative value of these values needs to be assessed.
Keywords
Agency Authenticity Autonomy Best interests Kant Mill
The problem
There is a type of ethical dilemma that consistently troubles clinicians and
bioethicists alike. It arises when a clearly competent patient makes a choice that
seems to be contrary not just to his interests but also to his own prior value
commitments. In such cases, the patient seems to be acting in ways that do not make
sense to his doctors or to his loved ones, because his decision seems inconsistent
with his past decisions or with people’s ideas of who he is.
D. Brudney (&)
Department of Philosophy, The University of Chicago, 1115 East 58th Street, Chicago,
IL 60637, USA
e-mail: [email protected]
J. Lantos
University of Missouri at Kansas City and Children’s Mercy Bioethics Center, Kansas City,
MO, USA
e-mail: [email protected]
123
D. Brudney, J. Lantos
In such situations clinicians have to decide whether to accept the patient’s
statement about his desires or, if not, how to justify overriding a clearly stated
choice. Often, they seek help from psychiatrists, ethics consultants, lawyers,
chaplains, family members, and social workers. The role of these helpers is not
well-defined. It is, in part, to change the patient’s mind. It is, in part, to try to tell a
story about the patient that makes sense. It is, in part, to defend the patient’s right to
make a choice, even if that choice seems troubling.
When these experts bring their skills to bear on a particular case, they often find
ways out of the troubling dictates of the autonomy paradigm. Sometimes the
patient’s inconsistencies are interpreted as a sign of incompetence. This allows a
procedural solution that ducks the ethical problem. In other cases the patient’s
statement of his own wishes can be so ambivalent or ambiguous that different
interpreters draw different conclusions about what the patient ‘‘really’’ wants.
In this paper, we explore the implications of a third approach to this class of
cases. We assume that the patient is clearly competent; we also assume that his
stated wishes are clear and unambiguous, indicating a specific preference for
treatment or non-treatment. In spite of these stubborn facts, we think it is sometimes
justified for clinicians to wonder how to respect a patient’s autonomy when the
patient’s own choices seem to be inconsistent with some idea of who he is and what
they know about his beliefs and values.
In such cases, the physician is not trying to substitute her own values for those of
the patient. Rather, the patient seems to be acting on a value that does not fit with
the values he has long held. What worries the physician is an apparent conflict
between a momentary but, by the standard criteria, competent choice of an end
versus the ends that the patient has cared about through much of his life. In the type
of case we want to discuss, the physician might actually agree with the patient’s
choice and even think that she would make the same choice herself. The problem is
that she is not certain that the choice is a reflection of the patient’s most deeply held
values. If it is not, then the clinician wonders if it is a truly autonomous choice.
In general the right of competent patients to make choices is respected because it
is thought that those choices have both instrumental and intrinsic value. It is thought
that they have instrumental value because patients generally know best what is in
their own interest. Allowing treatment to be guided by patient choice is thought
usually to lead to the decision that is best for that patient. But choice is also said to
have intrinsic value in the sense that, apart from whether the choice leads to good
consequences for the patient, he is entitled to make his own decisions, to run his
own life—even if he does so badly and makes choices that are not in his own
interest.
These two types of values tend to reinforce one another. In cases where the
physician does not believe that a patient’s choice has instrumental value, she can fall
back on the belief that it has intrinsic value. In these cases the physician behaves, in
effect, as if the intrinsic value of autonomous patient choice is more valuable than
life itself. We do not deny this thesis about value. Rather, our claim is that in clinical
settings patient autonomy has two distinct components. Our focus is on cases in
which these two components are in conflict. The question, then, is, which is most
plausibly more important than life itself?
123
Agency and authenticity
Two illustrative cases
Case #1
The first case that illustrates this dilemma comes from Jodi Halpern’s book, From
Detached Concern to Empathy. Halpern describes a patient, Ms. G:
A medical-surgical team at an East Coast hospital requested a psychiatric
consultation for Ms. G, a fifty-six-year-old white woman with diabetes
mellitus who had just had her second above-the-knee amputation. She had a
long history of kidney failure, was not a candidate for a transplant, and
required dialysis three times a week. Although she had willingly come to the
hospital for surgery, she was now refusing dialysis, even though she knew that
without it she would die in a matter of days. She refused to tell the medical
team why, so they wanted both a psychiatrist and an ethicist to evaluate her
decision-making capacity. [1, p. 1]
Halpern, as the ethicist who was called to consult on the case, learns that,
two years before, after her first amputation, Ms. G had been depressed and hopeless.
With psychiatric treatment, however, she had recovered her optimism and energy.
She had gone on to enjoy her work as an artist and to continue her active social life.
But this time, something is different. Halpern explains that the difference is that Ms.
G has just learned that her husband is leaving her for another woman.
Ms. G’s psychiatrist and her internist both feel that she is competent, that she
understands the decision she is making, and that her decision must be respected.
Halpern thinks that it need not be respected because Ms. G’s identity is distorted by
the emotional trauma of her husband’s decision to leave her. She is not herself, in
the sense that she is no longer thinking in terms of the values that she has long lived
by. Both groups appeal to Ms. G’s autonomy in justifying their opinions.
Case #2
The case of Dr. Michael DeBakey’s surgery for an aortic aneurysm was told in a
New York Times article by physician–journalist Lawrence Altman [2]. Briefly,
DeBakey, who invented the surgical procedure that is used worldwide for aortic
aneurysm, and who was thus one of the leading authorities in the world on the
diagnosis and treatment of this disease, developed the classic symptoms of a
dissecting aortic aneurysm while he was at home alone one evening. Although he
thought he was going to die, he did not call a doctor or go to the hospital. When his
wife returned and doctors were summoned, they insisted that he go to the hospital.
He refused, stating that he thought he would heal spontaneously. He continued to
worsen, eventually agreed to be hospitalized, but continued to refuse surgery. He
did not, however, request hospice or palliative care. At his insistence, a Do-NotResuscitate order was entered into the chart. He then lapsed into a coma. At that
point, the doctors were not sure whether to operate. On the one hand, he had not
given them permission to do so; on the other hand, he had stayed in the hospital
under their care. His wife insisted that he should be operated on. Some doctors
123
D. Brudney, J. Lantos
refused; others agreed. All thought they were doing what DeBakey would have
wanted.
Agency and authenticity
Philosophers have understood autonomy in many ways. We will focus on two
elements of autonomy, each of which is tied to a basic human capacity. We start
with the capacity to choose, to take something as a sufficient reason to act. At issue
is not the capacity simply to pursue what one desires. Animals do that—but animals
do not act for reasons. They do not judge that something is a sufficient reason for
action. Nor are we talking about the capacity to act spontaneously, for instance, at a
sporting event to jump up and cheer. There may be value to such spontaneity but,
like the actions of animals, this is not something with the value that commands the
respect that is accorded to autonomy.
The capacity to make a choice is, then, the capacity to decide on the basis of
reasons (including bad reasons). The central idea is that the fact that I desire X does
not entail that I must act on that desire and pursue X. That I desire X is a reason to
pursue it; nevertheless, it might not be a sufficient reason. It is up to me to decide
whether, overall, there is sufficient reason to pursue X. According to Kant in The
Metaphysics of Morals, our capacity to make a choice, ‘‘to set ends,’’ is what is
distinctively human (separating Menschheit from Tierheit) [3, p. 154]. What Kant
stresses there is our capacity to accept or to reject our desires, in some sense, to be
independent of them. He stresses the capacity for agency.
One way to ground the respect that we, as a society, have for patient choice, to
ground the value that we find in it, is to see it in terms of agency.1 A patient who is
competent to make a particular decision—who can understand and act on the basis
of the pros and cons of the treatment options—is an agent. He can exercise his will.
One way to understand why patient choice is so valuable is to see it as an instance of
agency, something philosophers have often thought to be of enormous value
because it is the way in which, unlike other animals, we are not merely creatures of
desire.2
1
A word should be said about Kant. There is an unfortunate tendency for bioethicists to appeal only to
the Kant of the Groundwork of the Metaphysics of Morals. However, this is merely one book among
several that are fundamental for Kant’s moral thought. Limiting oneself to the Groundwork distorts one’s
understanding of that moral thought—and even of the Groundwork, itself. In the Groundwork, Kant
claims that the good will is the only thing whose goodness is unconditional (ohne Einschränkung). This
claim is often, correctly, tied to his use, in the Groundwork, of the term ‘‘autonomy’’: autonomy, in Kant’s
use, obtains only when one acts with a good will, i.e., from respect for the moral law. In his subsequent
works, however, Kant came to see that autonomy and freedom are different. The latter can obtain even
when the former is absent; otherwise, there could be no responsibility for one’s immoral actions. In his
books The Metaphysics of Morals and Religion within the Boundaries of Mere Reason, Kant stresses that
what is distinctively human is the capacity to make choices, even immoral choices (indeed, it is the
capacity to make choices that may not be treated as a mere means). In understanding Kant’s contribution
to the foundations of bioethics, it is vital not to restrict oneself to the Groundwork.
2
Drawing on a different philosophical tradition, that of Aristotle and Aquinas, Philippa Foot has
emphasized this point. See Foot [4, pp. 52–65].
123
Agency and authenticity
However, ‘‘autonomy’’ can also have another meaning. It can refer to living one’s
own distinctive life, to constructing one’s life in accordance with one’s distinctive
beliefs and values. This ideal—of the self-directed individual—goes back to the
Renaissance but receives its canonical form in John Stuart Mill’s book On Liberty.3
Mill writes that ‘‘it is the privilege and proper condition of a human being, arrived at
the maturity of his faculties, to use and interpret experience in his own way’’ [5,
p. 58]. He stresses that we should not only make choices; we should form ourselves
at the deepest level so that our very desires are things that we can endorse and that
lead us to choices that consistently reflect those desires. ‘‘One whose desires and
impulses are not his own,’’ Mill writes, ‘‘has no character, no more than a steamengine has a character’’ [5, pp. 60–61]. Beyond making choices, the idea is to be—
or to become—oneself. Call this the capacity for authenticity.4
To see the difference between agency and authenticity, note that agency can be
fully exercised at each instant. Each choice can completely exercise the capacity.
Authenticity, by contrast, must be exercised over time, sometimes over a lifetime.
Over time, my authenticity projects me, my individual persona, onto the world.
Authenticity is a sustained achievement, agency a momentary one.
The point of authenticity is not just to make a choice, or even to make many
choices, but to make a life. The value that we look for in an authentic life is that it is
a life that I have made and made in a specific way because it is the life that I believe
fits me. An authentic choice is one that makes sense within the framework of the
beliefs and values that I affirm.
Note that autonomy does not preclude character change. A person may come to
judge that her life has hitherto been misguided, that she needs to launch herself in a
new direction. As long as she makes a change on the basis of her own beliefs and
reflections, her life is as authentic as that of the person whose views have not altered
over time. The unity of a life, on our view, is less in the constancy of its content than
in one’s leading it as the life that one has made and continues to make for oneself.5
Agency and authenticity are distinct and logically separable components of what
clinical ethics dubs ‘‘autonomy.’’ We suspect that, in practice, clinicians look for
both components in order to judge whether a patient is acting autonomously.
Agency seems to be the value behind the authority of decisional competence. If the
patient can understand the options before her and can see a sufficient reason to
choose option A over option B—that is, if the patient has the capacity to make a
decision, to exercise her will, about the issue at hand—then, with respect to that
issue, she has agency. We suspect that it is the value of agency that is tacitly
3
See Mill [5, ch. 3]. See also Feinberg [6, pp. 32–33]. For a discussion of authenticity in clinical
contexts, see Siegler and Goldblatt [7].
4
Like ‘‘autonomy,’’ the term ‘‘authenticity’’ has been used in many ways. Unfortunately, it is not
possible here to detail the distinctions between our usage and the myriad others.
5
It is also worth emphasizing that considerations of authenticity do not always point toward accepting
treatment. Ms. W, described on the next page, is one such example. But even with Ms. G, her situation
might have seemed to her so dire that the prospect of making for herself a new kind of life and, in effect, a
new kind of self might have appeared not worth the trouble. Here, considerations of authenticity might
have pointed toward refusing treatment. We thank an anonymous reviewer for pressing us to address this
issue.
123
D. Brudney, J. Lantos
appealed to in the thought that a decisionally competent patient ought to be allowed
to refuse treatment. On the other hand, when clinicians feel uncomfortable with
allowing a decisionally competent patient to refuse treatment because that refusal
seems inconsistent with who the patient is, then authenticity is at stake. In such
situations, clinicians may intuit that mere decisional competence does not reflect a
sufficiently robust value to justify going along with, say, the refusal of lifesaving
treatment. As in the cases of Ms. G or Dr. DeBakey, they want to see such a refusal
as part of a more or less stable and coherent set of beliefs and values, as flowing
from who the patient is. Then they can more easily see that they ought to respect the
choice to refuse treatment. At times, however, the powerful influence of a view of
autonomy as grounded in agency alone may lead them to dismiss or distrust those
intuitions.
We do not want to leave the impression that agency and authenticity usually
diverge. On the contrary, they usually fit together nicely. Take Ms. W, a 35 year old
Jehovah’s Witness, who refuses a lifesaving procedure because it would involve a
blood transfusion. She knows that to live she must have a transfusion but she
chooses to die in accordance with the precepts of her religion. This is an instance of
the exercise of both agency and authenticity. Ms. W understands her options and, as
a competent patient, makes a choice. And that choice fits well with her deeply held
and long-standing values and beliefs.
Which value is the crucial value?
In a common formulation of competing values, patient autonomy is pitted against
beneficence, that is, against a focus on the patient’s best interests. We have divided
the patient autonomy side into two branches, leaving three values, rather than two,
at stake in the clinical setting—autonomy-as-agency, autonomy-as-authenticity, and
best interests.
In the current American system, best interest considerations stand a chance
against autonomy only when the patient is not competent to make a decision and the
patient’s surrogate cannot say what the patient would have chosen to do. Limiting
best interest considerations this way is based both on affirmation of the value of
autonomy and on skepticism about doctors’ practical wisdom. We could challenge
this orthodoxy and ask whether a generally reasonable rule that limits best interest
considerations might have exceptions. We put this question aside, however, in order
to highlight the more fundamental issue of autonomy’s competing interpretations.
As noted, agency and authenticity usually point in the same direction yet in some
cases, for instance, those of DeBakey or Ms. G, they seem opposed. What the
patient says that he wants now seems inconsistent not with some conception of the
patient’s best interests but, rather, with who he is. Then the philosophical
disagreement between Dr. Halpern and her superiors, or between Dr. Debakey’s
various specialists, comes to the fore.
We believe that the value of agency alone, that is, not conjoined with the value of
authenticity, is insufficient to justify the refusal of lifesaving treatment. This is a
philosophical thesis whose proper defense would require a different and longer
123
Agency and authenticity
article. Still, the basic thought is straightforward. The mere exercise of a person’s
competent will, the mere exercise of choice, does not seem more valuable than
human life—at least not obviously so. For Kant, agency is tied to a particular
metaphysical picture. For him, our capacity to set ends distinguishes us from other
animals and links us to other possible rational beings, such as God or the angels.
Absent such a picture, it is not clear why we should think that agency has overriding
value. By contrast, we find quite plausible the thought that a basic part of an
acceptable human life is to live it in accordance with one’s deeply held beliefs and
values. Without agreeing with the content of her religious beliefs, we find plausible
Ms. W’s conviction that it is more important for her to end her life in accordance
with those beliefs than to continue life at the cost of violating them.6
Our claims, then, are as follows:
(1)
(2)
(3)
The moral justification for accepting a patient’s decision to refuse lifesaving
treatment is lessened to the extent that this decision, though made by a
decisionally competent patient, is less than authentic.
In cases in which the medical team believes that a patient’s decision to refuse
lifesaving treatment is less than authentic, the team should make additional
efforts to talk to the patient, to try to understand her reasons for her decision
and to try to see if those reasons fit into an adequate account of who the patient
is. This should be done, when possible, in consultation with the patient’s
family, friends, or life partner.
At the extreme, it is possible that a decisionally competent patient’s decision to
refuse treatment is sufficiently inauthentic that it would be wrong to accept
that refusal of treatment.
Objections
Right off, one might object that an attempt to base clinical decisions on
considerations of authenticity, rather than agency, is legally suspect. It might be
pressed that, legally, a doctor must accept the decision of her competent patient.
Even if Dr. Halpern wants to force treatment on Ms. G, she may not legally do so.
This objection need not detain us. It correctly describes the current legal situation.
Our question is whether that legal situation is as it should be. Furthermore, the legal
situation is not always so clear, legal guidelines vary from state to state, and there
are often ways to get around perceived legal requirements in complex cases.
More troubling is the objection that to compel Ms. G to have lifesaving treatment
on the grounds that her refusal is not an authentic choice seems to open the door to
6
Our sketch of the agency/authenticity distinction lacks adequate philosophical development. What is
needed is a richer account of what the two values amount to. As a first step, one might compare the work
of an agency advocate, Stephen Darwall (see especially [8, 9]), with that of Joseph Raz, who might be
cast as something like an authenticity advocate (see especially [10]). One might also look at many of the
essays of Harry Frankfurt in the collections The Importance of What We Care About [11] and Necessity,
Volition, and Love [12]. Finally, in a quite complex way, Christine Korsgaard’s discussion of agency and
integrity is of relevance; see [13].
123
D. Brudney, J. Lantos
letting doctors ignore patients’ refusals of treatment. This seems a slippery slope if
there ever was one. Does not our proposal merely return to old-fashioned
paternalism, now disguised as doctor-determined authenticity?
This is indeed a risk. However, it is a different risk than is usually involved in
what is labeled ‘‘paternalism.’’ Authenticity is not the same as best interests. The
doctor who believes authenticity is important and tries sincerely to understand the
basis for her patient’s choice in that patient’s deeply held beliefs and values is doing
something very different from the doctor who decides based upon her own opinion
about what is best for the patient.7 The doctor who values authenticity is trying to
respect what the patient—this person here, with a particular range of beliefs and
values—really wants.
Nevertheless, we do not want to deny that our view has a troubling implication.
Even if it is not paternalist in the sense of according the doctor independent
authority to determine what is best for the patient, our view does entail that there
could be cases in which a competent patient’s liberty to refuse treatment is not the
overriding consideration. No doubt such cases will be rare; moreover, they will
likely involve additional considerations that warrant acceding to the patient’s refusal
(legal concerns, slippery slope concerns). What we are pressing is that in some cases
the value of mere agency should not be seen as solely determinative, as
unchallengeable, as a trump. Patient refusal involves a value-theoretic uncertainty
that needs to be addressed.
Several other objections should be noted. First, talk of authenticity might seem to
commit us to the suspect thesis that there is a ‘‘true me,’’ some fundamental essence
of the specific agent. As we use it, though, the concept of authenticity is normative,
not metaphysical. It involves two claims: that people in fact tend to have
(somewhat) stable and coherent sets of basic beliefs and values, and that living in
accordance with those beliefs and values is usually a central good for that person.
No doubt, a person’s values can shift over time; what would count as an authentic
choice might then also shift. But whether there is a pre-existing ‘‘true me’’ is not at
issue.
Second, the ideal of authenticity might be challenged. One might reject reflection
and/or self-determination as giving value to a life. Instead, one might give pride of
place to whimsicality or to deference to authority. Authenticity is a substantive
value. We invoke it both because it seems to play a role in clinical decision-making
and because we think it is in fact of great value. Clearly, the latter claim needs
philosophical defense.8
Third, in pressing for authentic patient choice over mere agency, we might seem
to be advocating a form of ‘‘weak paternalism’’—accepting the patient’s values but
attempting to instantiate them by means the patient has not chosen. The usual
understanding of weak paternalism is that it involves interfering with a person
7
It should also be kept in mind that one cannot vindicate the value of agency by appealing to the
epistemic advantages of a rule that lets patients decide. The value of agency is precisely not tied to patient
knowledge (beyond the minimum needed for legal competency). The thought that the patient knows best
would put the stress not on the value of the exercise of the will (agency) but on the value of a good
outcome (however that is construed).
8
For a rejection of the ideal of authenticity, see Strawson [14].
123
Agency and authenticity
because she has made a mistake about the facts rather than because she has made a
mistake about values. As Gerald Dworkin puts it, ‘‘if a person tries to jump out of a
window believing he will float gently to the ground we may restrain him’’ [15].9
Actually, our focus differs from this. For us, beliefs about the facts are not in
question. In the cases at issue, the patient is assumed to have correct beliefs about
the facts. For us, the problem is that there appears to be a conflict in the patient’s
values—between his immediate preference, on the one hand, and, on the other hand,
the values he has long held and that have been significantly constitutive of who
he is.
Our view also raises worries that are purely practical. One might find something
appealing about the concept of authenticity and yet think that achieving authentic
patient choice is unlikely to be realizable in practice. To begin with, doctors simply
do not have the necessary time. The ideal of authenticity seems to presuppose
doctors who have known their patients over many years or who can spend many
hours with a new patient. In a modern medical system neither seems possible.
Moreover, to facilitate authentic patient choice and to judge when it obtains (and
what to do when it does) seems to require a kind of practical wisdom that we have
little reason to believe doctors possess. In terms of practicability, agency seems to
have a big advantage. In practice, it is likely to be much easier to satisfy the
conditions for being a competent agent than to satisfy the conditions for making an
authentic choice. Perhaps more important, it is likely to be much easier for an
ordinary doctor to know that the conditions for agency have been satisfied.
These are genuine worries. Still, to the extent that our arguments have weight,
they suggest that accommodation ought to be made, at least in some cases, for
practices that would promote authenticity. After all, medical practice has been made
more cumbersome by the requirement to obtain and document informed consent to
medical procedures. Because agency has been thought important, requirements
(often quite onerous) to facilitate it have been put in place. Our society has been
willing to change clinical practices in order to realize what it takes to be an
important moral value. Surely, we should at least look into the possibility of
practices that would promote authentic patient choice.
In any event, it is important to know one’s ideal. Of course, the ideal of authentic
choice cannot be reached. All ideals are unreachable. With any ideal, the most one
can do is to take steps in its direction. But to figure out which steps to take, the ideal
must first be identified.
If our medical institutions are to be regulated by the principle of patient choice,
including the choice to refuse lifesaving treatment, it is imperative that we have a
sufficient moral defense of that principle. If the value of agency does not provide a
sufficient defense, it would be wholly inadequate, indeed ridiculous, to say that,
nevertheless, it is a value that is practicable.
9
Gerald Dworkin defines weak paternalism as follows: ‘‘A weak paternalist believes that it is legitimate
to interfere with the means that agents choose to achieve their ends, if those means are likely to defeat
those ends. So if a person really prefers safety to convenience then it is legitimate to force them to wear
seatbelts…. Another way of putting this: we may interfere with mistakes about the facts but not mistakes
about values. So if a person tries to jump out of a window believing he will float gently to the ground we
may restrain him. If he jumps because he believes that it is important to be spontaneous we may not’’ [15].
123
D. Brudney, J. Lantos
We close with two hypothetical situations. Suppose that instead of needing longterm dialysis, Ms. G merely needs, but is refusing, one shot of a powerful antibiotic.
Imagine, further, that she has drifted off to sleep. Imagine that the doctor has the
syringe, it will take him barely a moment to inject her, and the injection will be done
by the time she awakes and realizes what has been done. This is the only chance—
inject her now or she dies. The agency advocate must hold that agency is so
important that any violation of it is worse than death.10 The authenticity advocate
might inject Ms. G and feel that, on balance, he was more respectful of Ms. G’s
autonomy by preserving her opportunity to exercise it than he would have been by
accepting her decision and foreclosing her future.
By contrast, imagine that the doctor could secretly, but against her wishes, give
Ms. W, the Jehovah’s Witness, a transfusion and so save her life. Some readers
might think the doctor should do so, but some might think he should not. Our point
is that in this case, it will seem morally more problematic to override patient
choice—and that is because, unlike Ms. G, Ms. W is trying to exercise not merely
her agency but also her capacity to live (and die) authentically.
Two values are at stake in patient choice. In particular cases, we may need to
assess their relative value. So the debate about which is the more important value
does have to be joined.11
References
1. Halpern, Jodi. 2001. From detached concern to empathy. Oxford: Oxford University Press.
2. Altman, Lawrence. 2006. The man on the table devised the surgery. New York Times, December 25.
3. Kant, Immanuel. 1996. The metaphysics of morals. Trans. and ed. Mary Gregor. Cambridge:
Cambridge University Press.
4. Foot, Philippa. 2001. Natural goodness. Oxford: Oxford University Press.
10
In defending the value of agency in medical contexts, people often invoke the ‘‘right to bodily
integrity.’’ If someone keeps me from choosing what to do with my body, my agency is violated in an
especially important way. On scrutiny, though, the issue turns out to be complicated. One way the bodily
integrity claim is often spelled out is via the claim that it would be morally wrong to prevent me from
taking a physical risk—to interfere with my body—as long as I am mentally competent and the proposed
action does not harm or imperil any third-party. Yet this is not clearly right. If my child is in a burning
building, I will want to rush in to try to save her. I would certainly be emotionally distraught, but I would
not be incompetent or irrational. Nevertheless, the police are likely physically to prevent me from
entering the building. Their reason will be that the risk to me is too great. (If preferred, the stage can be
set more fully by assuming that the fire marshal has already ordered the fire fighters out of the building.)
Libertarians might disagree with a law that requires the police to restrain me for my own good. However,
most people would probably accept this as a proper constraint on my risk-taking. At any rate, the case is
not obviously one in which the police would be morally wrong to restrain me. Bodily integrity is not
obviously more valuable than life itself.
11
One might think that both agency and authenticity are important values, and that in actual cases, they
should be balanced against one another (maybe even sometimes along with best interests considerations).
In the clinical setting one might favor value pluralism over value monism. This has some common sense
appeal. Still, value pluralism requires that, in many cases, someone balance the values and decide what
decision, on balance, is required. Authority must thus be put in the hands of a doctor or some other health
care professional. Logically, pluralism involves denying that the patient’s mere agency has overriding
authority.
123
Agency and authenticity
5. Mill, John Stuart. 1989. On liberty. In On liberty and other writings, ed. Stefan Collini. Cambridge:
Cambridge University Press.
6. Feinberg, Joel. 1986. The moral limits of the criminal law. Harm to self, vol 3. Oxford: Oxford
University Press.
7. Siegler, Mark, and Ann Dudley Goldblatt. 1981. Clinical intuition: A procedure for balancing the
rights of patients and the responsibilities of physicians. In The law-medicine relation: A philosophical
exploration, ed. S.F. Spicker, J.M. Healey, and H.T. Engelhardt, 5–31. Boston: D. Reidel Publishing
Company.
8. Darwall, Stephen. 2006. The second person standpoint. Cambridge, MA: Harvard University Press.
9. Darwall, Stephen. 2006. The value of autonomy and autonomy of the will. Ethics 116: 263–284.
10. Raz, Joseph. 1986. The morality of freedom. Oxford: Oxford University Press.
11. Frankfurt, Harry. 1988. The importance of what we care about. Cambridge: Cambridge University
Press.
12. Frankfurt, Harry. 1999. Necessity, volition, and love. Cambridge: Cambridge University Press.
13. Korsgaard, Christine. 2009. Self-constitution: Agency, identity, and integrity. New York: Oxford
University Press.
14. Strawson, Galen. 2004. Against narrativity. Ratio 17: 428–452.
15. Dworkin, Gerald. 2010. Paternalism. Stanford encyclopedia of philosophy. http://plato.stanford.edu/
entries/paternalism/.
123